Patients who are newly diagnosed with cancer will almost inevitably be placed under an enormous level of stress, and addressing their fears and concerns is an important part of their clinical management.

This stress may be particularly acute in women with breast cancer who often feel well at the point of diagnosis. 

These women suddenly find themselves confronted with having to make important and life-changing decisions about the treatment of a serious disease, with the decision-making process often compressed into a few weeks.

In an understandable desire to get rid of the cancer quickly and move on with their lives, many women will accept any treatment offered to them, however aggressive, and many physicians will let patients’ emotional need for aggressive treatment affect their clinical choices, even when the clinical indications are uncertain.

Contralateral prophylactic mastectomy (CPM), or a double mastectomy in which the healthy breast is removed alongside the cancerous one in order to reduce the risk of recurrence, is a particularly aggressive treatment that is, nevertheless, often requested by patients.

Its use has increased markedly in recent years and it is much more often performed than bilateral prophylactic mastectomy in healthy women at a very high risk of developing breast cancer.

Steven J. Katz of the University of Michigan, Ann Arbor, MI, USA and Monica Morrow of Memorial Sloan-Kettering Cancer Center, New York, NY, USA have now written a useful Viewpoint article in the Journal of the American Medical Association exploring how clinicians might increase patients’ peace of mind without resorting to such an aggressive therapy in the absence of real clinical need.

They explain that the risk of a second primary breast tumour in the breast unaffected at the time of first diagnosis is low compared to that of distant metastases and that it is decreasing further with improvements in systemic therapy.

A small percentage of patients with specific genetic aberrations such as mutations in the breast cancer susceptibility genes BRCA1 and BRCA2 are known to be at much increased risk of a second primary tumour.

Current guidelines therefore only support contralateral prophylactic mastectomy in patients who are known to be at high risk.

Few patients who request and receive CPM, however, are in one of these groups; most are motivated by a fear of recurrence that is entirely understandable but that is disproportionate to the actual risk.

Most of these women could be treated very well with lumpectomy, an operation that conserves healthy breast tissue, has a shorter recovery time and fewer long term adverse effects.

Surgeons are increasingly uncomfortable with the idea of performing extensive operations that they consider unnecessary, but are under pressure to acquiesce to patients’ requests for these.

In the US, almost all insurance providers cover CPM for breast cancer independent of an individual patient’s risk factors, and surgeons who refuse such treatment to women at average risk may lose valuable patients to others who are prepared to perform it.

This issue underlines the need for clinicians to find ways of addressing patients’ fears without resorting to unnecessarily aggressive treatment options.

Katz and Morrow suggest that patient education is a key factor: physicians need to explain the risks and benefits of each treatment option clearly to their patients, and in this case to emphasise the benefits offered by improved systemic therapy.

Patients should also be encouraged to think deliberately about each option and should not be – or consider themselves to be – rushed into making decisions.

In an insurance based system such as the US, restricting insurance cover for CPM to patients with risk factors for second primary tumours such as BRCA mutations should also reduce the number of unnecessary operations performed.

In conclusion, Katz and Morrow stress the challenge for surgeons to counter the belief held by many patients and some of their colleagues that “bigger is better” in breast treatment options and so reduce the numbers of unnecessary, invasive and expensive contralateral prophylactic mastectomies that are performed.  

Reference

Katz. S.J. and Morrow, M. (2013). Contralateral Prophylactic Mastectomy for Breast Cancer: Addressing Peace of Mind. JAMA, published online ahead of print 1 August 2013. doi: 10.1001/jama.2013.101055